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Memory and vigilance training to improve social perception in schizophrenia
SCHIZOPHRENIA RESEARCH SchizophreniaResearch 17 ( 1995) 257-265
ELSEVIER
Memory and vigilance training to improve social perception in schizophrenia Patrick W. Corrigan *, Joyce Nugent Hirschbeck, Michelle Wolfe Llniversity of Chicago Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tinley Park, IL 60477. USA Received 28 November 1994; revision received 23 January 1995; accepted 30 January 1995
Abstract
Previous research has suggested that social cue recognition in schizophrenia may be significantly associated with visual vigilance and verbal memory. Therefore, we predicted that subjects who participated in a cognitive rehabilitation program that incorporated vigilance and memory training strategies would show significantly better social cue recognition than subjects participating in vigilance training alone. Forty subjects with a DSM-III-R diagnosis of schizophrenia or schizoaffective disorder were randomly assigned to either a vigilance-alone or a vigilance-plusmemory training condition. Results showed that subjects in the vigilance-plus-memory condition were able to identify social cues in the videotaped training materials significantly better than subjects in the vigilance-alone condition. This difference was evident in an independent measure of social cue recognition and was present at a 48 h follow-up. Implications for future development of cognitive rehabilitation for schizophrenia were discussed. Keywords: Social cue recognition; Memory training; Vigilance training; (Schizophrenia)
1. Introduction
Clinical research has consistently shown that, in concerl with careful titration of neuroleptic medication, behavioral rehabilitation strategies, like social skills training, effectively reverse the downhill trend in the deteriorating interpersonal skills of some schizophrenia patients. Patients participating in social skills training programs have been found to increase their range of prosocial behaviors, to diminish their psychotic symptoms, and to decrease their time in the hospital (Bellack et al., 1984; Hogarty et al., 1986, 1991; Wallace * Corresponding author. 0920-9964/95/$09.50© 1995ElsevierScienceB.V. All rights reserved SSD1 0920-9964(95)00008-9
and Liberman, 1985). These effects seem to be limited, however; many patients who demonstrate significant cognitive deficits seem to be refractory to traditional skills training strategies (Liberman et al., 1985; Massel et al., 1991). Therefore, development of cognitive rehabilitation strategies may facilitate social skill learning and may improve overall interpersonal functioning. In order to meet this goal, research teams have attempted to conceptualize interpersonal functioning and social skills training in terms of information processing functions (Bellack et al., 1989; Corrigan, Schade and Liberman, 1992). Recent studies have evaluated the relationships between two information processing functions - visual
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vigilance and verbal recall 1 - and domains of social cognitive functioning including psychosocial skill learning and social cue recognition. In terms of psychosocial skill learning, studies have found significant relationships between skill acquisition and measures of visual vigilance (Bowen et al., 1994; Kern et al., 1992) and short term, verbal recall (Corrigan et al., 1994; Kern, Green and Satz, 1992; Mueser et al., 1991). A similar pattern was found with social cue recognition. Social cue recognition has been distinguished from other information processing tasks by the content of these tasks which are believed to be more ecologically valid (Ostrom, 1984; Penn et al., 1994). The foci of social cue recognition tasks are concerned with relatively molar information, focus on behavioral and individual differences, tend to be labile, act as their own causal agent, and interact with the perceiver. One study examined the relationship between social cognition and information processing measures. Results showed social cue recognition to be significantly associated with both recall memory and visual vigilance (Corrigan et al., 1994). Therefore, improving deficits in social cue recognition seemed like a logical first step in remediating cognitive dysfunctions that interfere with social skill learning and interpersonal competence, and therefore was the target of the cognitive interventions discussed in this paper. Findings from the above literature on descriptive psychopathology suggest that cognitive rehabilitation strategies which attempt to improve recognition of interpersonal cues might be more successful when incorporating interventions that address deficits in vigilance and recall memory. Reviews of the literature on cognitive rehabilitation of schizophrenia have showed, however, that most studies have used various 'vigilance' strategies alone as the basis of their rehabilitative approach (Corrigan 1 Information processing is a complex construct that has been explained by various models including serial processing (Sternberg, 1966, 1967), cognitive capacity (Kahneman, 1973), and parallel distributed processing (McLeUand et al., 1986). Description of these models exceeds the scope of this paper. The two processes targeted in this paper were selected because they have been widely studied in laboratory-based research of cognition in schizophrenia (Nuechterlein and Dawson, 1984).
and Storzbach, 1993; Green, 1993). Investigators conducting vigilance enhancement studies assumed that primary deficits in vigilance accounted for subsequent deficits in memory; therefore, remediation of vigilance deficits should clear memory dysfunctions (McGhie and Chapman, 1961; Silverman, 1964; Venables, 1964). Despite this assumption, few studies of cognitive rehabilitation have actually examined the effects of remediated vigilance on more complex memory and encoding studies. One well-controlled study failed to find an association between improvements in vigilance processes and subsequent increments in encoding and memory (Wagner, 1968). If this dissociation is supported in future studies, then significant improvement of social perception may not be addressed sufficiently by 'vigilance' interventions alone. Much of this research has been completed on laboratory-based stimuli; interventions targeting social cognitive deficits have been lacking. The purpose of this study was to compare the effects of two cognitive rehabilitation approaches on the social cue perception of patients with schizophrenia. Vigilance training alone was contrasted to a training package that combined vigilance enhancement and semantic encoding; the latter intervention had been shown to remediate recall memory deficits in schizophrenia (Koh et al., 1976). Vigilance-plus-memory training was expected to yield superior effects on social cue recognition than vigilance-alone.
2. M e ~ o ~
2.1. Subjects Forty-six individuals who were either inpatients at Tinley Park Mental Health Center (n---18) or outpatients at the University of Chicago Partial Hospitalization Program (n= 28) were asked to participate in this study. Patients who agreed to participate were initially included if they had: a DSM-III-R chart diagnosis of schizophrenia or schizoaffective disorder, were between the age of 18 and 55 years, had no chart history of substance abuse in the past six months nor any history of tolerance or withdrawal during their lifetime, had
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corrected vision of at least 20/30 as measured on the Snellen Eye Chart, exceeded a third grade reading level as measured on the Wide Range Achievement Test-Revised (Jastak and Wilkinson, 1984), and had no chart history of neurological disorder or developmental disability. DSM-III-R diagnoses were validated by completion of the Mood and Psychotic Symptoms Modules of the Structured Clinical Interview for DSM-III-R (SCID: Spitzer et al., 1990). In addition, the Psychoactive Substance Use Disorders Module from the SCID was administered to assess history of recent drug dependence or abuse. The SCID was administered by individuals trained to a kappa of at least 0.60 with consensus criteria from our lab. Fort) subjects participated in the study; six declined to participate. The sample had a mean age of 35.3 years (SD= 10.1) and had completed 12.6 (SD=2.1) years of education on average. Subjects were 55% female, 57.5% African American and 42.5% white. Seventy-five percent of the sample was single, 10% was married, and 15% was divorced or widowed. On average, the sample had spent 60.7 (SD =73.6) of the previous 180 days in the hospital; 35.0% of the sample were inpatients at the time of the study. Thirty-eight of the patients received antipsychotic medication; mean dose in chlorpromazine equivalents equaled 711 mgs (SD=522). Seventeen patients received benztropine for side effects; mean dose equaled 3.5 rags (SD=3.6). 2.2. Predictor measures
Patients selected to participate in the study completed two measures that have been shown to be significantly associated with performance on the social cue recognition tasks: verbal recall/ recognition and psychiatric symptomatology (Corrigan et al., 1994). 2.3. Rev auditory verbal learning task (RAVLT)
Ability to recognize and recall word lists was measured by administering the RAVLT (Rey, 1964). Subjects were instructed to listen to a list of 15 common words read by the examiner. When
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the examiner finished the list, subjects repeated aloud as many of the words as they could remember. The examiner then repeated the entire list two more times with subjects recalling words at the end of recitation. The recall score equaled total number of correctly identified words for the three trials. After a fifteen minute interference task, subjects were instructed to read a paragraph and circle words that were included in the stimulus list. Number of correctly circled words represented the recognition score. 2.4. Brief psychiatric rating scale (BPRS)
Subjects were administered the expanded version of the BPRS to measure psychiatric symptoms (Lukoff et al., 1986). Raters conducting BPRS interviews were previously trained to a minimum intraclass correlation coefficient (ICC( 1,1 ): Shrout and Fleiss, 1979) of 0.80 according to criterion ratings established at our lab. Two summary scores, identified in a factor analysis by Overall et al. (1967) were determined: a Thinking Disturbance Factor (conceptual disorganization + hallucinations + unusual thought content) and a Withdrawal/Retardation Factor (blunted affect + emotional withdrawal + motor retardation). 2.5. Training conditions
After completing the predictor variables, patients were randomly assigned to either vigilance-alone or vigilance-plus-memory training. To diminish variables that might confound training effects, the stimulus materials, training environment, and length of training sessions were similar across conditions. The stimulus material for both training conditions was eight videotaped vignettes from the Social Cue Recognition Test (SCRT: Corrigan and Green, 1993). SCRT vignettes are 30 to 45 s long and include two or three actors engaged in either low emotion (e.g., two friends assembling a puzzle) or high emotion (e.g., a husband and wife fighting about their children) situations. All training sessions were conducted in the cognition laboratory at the University of Chicago Center for Psychiatric Rehabilitation.
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Training in both conditions was completed in one 60-minute session. Vigilance training comprised three strategies self-instruction, salient cues, and repeated practice that had been shown to improve the vigilance of schizophrenia subjects on information processing tasks (Meichenbaum, 1969; Meiselman, 1973). During a typical training session, subjects were seated in front of the video monitor on which SCRT vignettes were presented and asked whether they were 'ready to attend to the task' prior to presenting the vignette. They were then given a card with a self-instructional message prior to each vignette which they were told to say aloud (e.g., 'The scene is going to flash on the screen soon. I should watch with my eyes and listen with my ears.'). Subjects were then shown the videotaped vignettes twice to facilitate repeated practice. Training per se requires patients to 'learn something' as a result of the intervention. In vigilance training, patients learned to self-instruct a message about attending to the stimulus array. Vigilance-plus-memory training combined the three strategies discussed above with semantic elaboration, a neuropsychological training strategy that has been shown to remediate memory deficits (Gouvier et al., 1986; Koh et al., 1981; Koh et al., 1976). When participating in semantic elaboration, subjects were instructed, prior to viewing the vignette, to put the gist of the story in their own words. The self-instructional message was, 'I should try to put the story into my own words'. After viewing the vignette, subjects in the vigilance-plus-memory condition were asked to say aloud what happened in the story. Subjects who were not able to report key aspects of the situation, as outlined in the training manual, were asked questions by the examiner that facilitated encoding of the situation: 'What did the actors say in this situation? What did they do in this situation? Why did they say (or do) that? How do you think they felt in this situation? What do you think may happen next?'. Subjects were urged to put responses in their own words rather than repeat the actors' lines. Subjects were also provided a list of 'feeling words', divided into 'good' and 'bad' feelings, to help them choose responses to the question about how actors felt in the situation. -
2.6. Training fidelity Trainers conducting the sessions (JNH and MW) had met competency criteria on each condition during two pilot sessions prior to working with patients. Actual training sessions were also videotaped and subsequently rated by two independent raters on a measure of fidelity that summarized the competency criteria. The fidelity instrument contained 137 training behaviors which trainers were supposed to demonstrate during the sixty minute session; trainers were expected to show 63 behaviors when engaged in vigilance training and 74 behaviors for vigilance-plusmemory. Sixteen of the forty training sessions were randomly selected and rated by two independent raters on the fidelity checklist; raters were blind to hypotheses of the study and patient's training condition. The occurrence agreement (Hartmann, 1982) representing their interrater reliability was 0.92. The mean percent of training behaviors observed for each of the training strategies was 95.1% for vigilance alone and 94.2% (SD = 5.1 and 6.8) vigilance-plus-memory. 2. 7. Dependent measures Immediately after completing training exercises on each of the SCRT vignettes, subjects answered 36 true-false questions about that vignette. Hence, the sixty minute training session included the time necessary to conduct the vigilance-plus-memory or vigilance-alone training and the time to answer the 36 true-false questions for each of the vignettes. A sample question was 'True or false. At the end of the scene, Carl sat down at the table'. Previous research on the SCRT showed these questions to be reliable and valid measures of the social cue recognition of severely mentally ill adults (Corrigan et al., 1990; Corrigan and Green, 1993). Social cue recognition was also assessed on an independent measure of cue recognition - the Cue Recognition Test (CRT: Corrigan et al., 1992) after the sixty minute training session was completed. The CRT consists of eight videotaped vignettes depicting persons involved in interpersonal problems. Subjects answer eighteen true-
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false questions after each vignette; e.g., 'True or false. Barbara is standing at the front of the line'. The CRT has been shown to be reliable and correlates highly with SCRT performance (Corrigan et al., 1992). The tests of social cue recognition (the SCRT and the CRT) each yielded two outcome measures: correct identification rate (percent of true items reported as true) and false alarm rate (percent of false items reported as true). These indices may be biased, however, by the perceived payoffs for correct identifications and perceived penalties for incorrect attributions (Davies and Parasuraman, 1982). For example, subjects participating in a study where they are reimbursed $5.00 for correct identifications are more likely to say false items are true than subjects who are fined $5.00 for false alarms. Therefore, a nonbiased measure of cue sensitivity (A') was determined from correct identification and false alarm rates for the SCRT and CRTZ; this has been shown to be a valid index of memory in general (Snodgrass and Corwin, 1988), and of social cue recognition in particular (Corrigan and Green, 1993). To assess maintenance of training effects, the SCRT and CRT were re-administered at a 48 hour follow-up.
3. Results
The mean and standard deviations of demographic and predictor variables for the vigilanceplus-memory and vigilance-alone training conditions were summarized in Table 1. The two groups participating in each condition were not found to differ significantly on gender, marital status, age, education, or days hospitalized during the previous six months (p > 0.20). The two groups were shown to differ in terms of ethnicity, with more African Americans being randomly assigned to the vigilance-alone training condition (Xz = 5.01, p < 0.05 ). None of the demographic variables in Table 1 were
1 (CI-FA)(I+CI-FA) 2A' = 9 q4CI(1 - F A ) where CI=correct identification and FA=false alarm rate.
Table 1 Means and standard deviations of demographic and predictor variables for the vigilance-plus-memory and vigilance-alone training conditions Vigilance-plus-memory Vigilance-alone training training (n=20) (n=20) Gender Ethnicity Marital status
Age Education Antipsychotic dose Benztropine dose Days hospitalized BPRS Think Disturb BPRS With/Retard Rey Recall Rey Recognition
55.0% female 60.0% white 40.0% afr amer 75.0% single 5.0% married 20.0% wid/div 35.9 _+10.9 12.6 +_2.2 705 + 513 3.8 +_3.7 59.9 +_74.1 7.8_+3.2 4.5_+2.2 19.7 + 6.2 9.9 +4.0
55.0% female 25.0% white 75.0% afr amer 75.0% single 15.0% married 10.0% wid/div 34.7 _+9,5 12.6 +_2.0 717 + 531 3.3 _+3.6 61.6 +__75.1 7.4+3.4 5.2_+2.5 17.8 _+4.4 10.3 _+3.9
BPRS: Brief Psychiatric Rating Scale
found to covary significantly with A' on the SCRT or CRT (p>0.15). No significant differences were found in predictor variables (i.e., RAVLT and BPRS) across groups (p >0.20). The correlations between these variables and the social cue recognition outcome measures are summarized in Table 2. Results seem to support earlier research which showed a significant association between verbal memory and social cue recognition (Corrigan et al., 1994). In particuTable 2 Pearson product moment correlations between predictor measures and measures of cue sensitivity (SCRT A' and CRT A'I at post-test and follow-up SCRT A'
CRT A'
Post-test Follow-up Post-test Follow-up BPRS Think Disturb - 0 . 2 2 -0.15 -0.11 -0.12 BPRS With/Retard -0.27 -0.37 -0.19 -0.20 Rey Recall 0.43** 0.41"* 0.36* 0.26 Rey Recognition 0.42** 0.50*** 0.48** 0.37* * p<0.05. ** p<0.01. *** p<0.001 Correlation coefficients in italics met the Bonferroni Criterion for significance.
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lar, seven of the eight correlation coefficients representing associations between social cue recognition and verbal memory were significant; two of these associations met the Bonferroni criterion for significance. Contrast this pattern to the associations between psychiatric symptoms and social cue recognition. Only one correlation coefficient was significant, the association between Withdrawal/ Retardation on the BPRS and the SCRT sensitivity score at follow-up. No significant associations were found between Thinking Disturbance and any of the measures of social cue recognition. Despite this pattern, results of a statistical test for differences between correlations showed only one pair of correlation coefficients - the coefficient representing the association of Thinking Disturbance and post-test CRT A' versus the coefficient representing the association of Rey Recognition with follow-up SCRT A' - to be significantly different
(p<0.05). 3.1. Differences in vigilance-plus-memory versus vigilance-alone training conditions Means and standard deviations for the sensitivity (A') of SCRT and CRT scores at post-test and follow-up are summarized in Table 3. Results of a 2 x 2 MANOVA (condition by trial) with SCRT and CRT A's as the dependent measure showed a significant main effect for condition (F(1,38)= 5.65, p < 0 . 0 5 ) but not for trial (F(1,38)=0.02, n.s.) or the interaction (F(1,38) = 0.02, n.s.). Table 3 Scores on the Social Cue Recognition Test (SCRT) and the Cue Recognition Test (CRT) for subjects in the vigilance-plusmemory and vigilance-alone conditions after training and at 48 h follow-up
SCRT A r CRT A'
Vigilance-plusmemory training (n=20)
Vigilance-alone training (n=20)
Post-test
Follow-up
Post-test
Follow-up
0.89 (0.04) 0.93 (0.05)
0.89 (0.05) 0.93 (0.04)
0.83 (0.09) 0.88 (0.07)
0.84 (0.10) 0.88 (0.11)
Standard deviations included parenthetically.
A subsequent 2 x 2 ANOVA with SCRT A' as the dependent variable showed a significant effect for condition (F(1,38) = 5.53, p < 0.05). The trial effect and interaction were non-significant (F(1,38)=0.04 and F(1,38)=0.29 respectively). Post hoc oneway ANOVAs showed that SCRT A' was significantly higher for subjects in the vigilance-plus-memory training condition, compared to individuals in the vigilance-alone condition, at post-test (F(1,38)=6.43, p<0.05) and at followup (F(1,38) =4.30, p<0.05). A 2 x 2 ANOVA was also conducted with CRT A' as the dependent variable; it showed a significant effect for condition (F(1,38)=4.68, p <0.05) but not trial (F(1,38)=0.00) or the interaction (F(1,38)= 0.23). Post hoc oneway ANOVAs also showed that CRT A' was significantly higher for subjects in the vigilance-plus-memory training condition, compared to vigilance-alone at post-test (F(1,38) = 5.43, p < 0.05). Nonsignificant trends suggested a between group CRT A' difference at follow-up (F(1,38) = 3.63, p = 0.06).
4. Discussion Subjects in a vigilance-plus-memory enhancement condition were better able to recognize social cues presented in videotaped vignettes than subjects participating in a vigilance-alone, control condition. This effect was shown on both the stimulus materials on which training was conducted, as well as on an independent measure of social cue recognition. Therefore, the combination of semantic elaboration and self-instruction seems to yield greater cue recognition scores than vigilance strategies alone. The post hoc analysis illustrates one of the short falls in this study; namely, the size of the vigilanceplus-memory effect was not determined directly by collecting SCRT scores prior to conducting the rehabilitation intervention. A repeated measures design would allow the reader to determine the extent of change from baseline. The SCRT could not be administered at pretest in this study, however, because vignettes from the measure were used as training materials in the study. This problem
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could be obviated in future research by using training materials from other videotaped vignettes. Findings from this study showed that significant differences in the effects of vigilance-plus-memory versus vigilance-alone were present 48 hours later. Maintenance of therapeutic effects is an important finding, especially if it is replicated in subsequent research in which longer follow-ups are used. It is unclear from this study, however, whether maintenance of treatment effects is due to change in the theoretical mechanism that accounts for social cue recognition (e.g., improved social recall memory per se) or to learning a cognitive prosthetic (i.e., the self-instructional message) that, when used in the future, will help subjects perceive social situations better. Future research can resolve this question by randomly assigning subjects to semantic elaboration plus self-instruction versus semantic elaboration alone. Some researchers argue that clinicians need to strategically incorporate interventions into a treatment protocol which will maintain a treatment effect over time rather than assume that improvement will naturally endure (Stokes and Baer, 1977). Therefore, we expect that self-instruction will be the essential component for maintaining the treatment effect in this study. We attributed the significant vigilance-plusmemory effect to improvement of the recognition and recall memory of participating subjects. This finding is consistent with earlier research which showed that word and facial recognition improved significantly in patients who participated in semantic elaboration (Koh et al., 1981; Koh et al., 1976). However, neither the studies conducted by Koh and his colleagues nor the research described in this paper has shown that this effect is specifically due to improved recall or recognition. Future research would need to include independent evidence of improvement in recall or recognition after training to assert the specificity of our finding. Alternatively, perhaps the combination of selfinstruction and semantic elaboration therapeutically improves an earlier stage in the information processing series (e.g., vigilance) which subsequently enhances memory. Attempts to isolate the effects of cognitive interventions vis-a-vis specific information processes are difficult because of the serial nature of cognition. Nevertheless, the effort
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is important for practical reasons. Demonstrating that the vigilance-plus-memory procedure used to improve social cue recognition in fact enhanced recall memory suggests that other memory enhancement procedures (e.g., guided imagery, use of mnemonics) may also be helpful for schizophrenia patients (Corrigan and Yudofsky, in press). Morrison and Bellack (1981) have argued that patients who perceive and understand social cues may demonstrate relatively better social functioning. Therefore, improvement of interpersonal cue recognition is likely to correspond with a concomitant gain in social learning and social skill. However, increments in social cue recognition alone are probably not sufficient to improve social functioning. The macro construct of social functioning comprises several other social cognitive components - comprehension of the rules that define a social situation, development of a response to the demands of a situation given these rules, retrieval of various actions that may be appropriate to the response - which may be deficient in schizophrenia subjects. Change in these functions may yield clinically meaningful changes in prominent symptoms like paranoia and social anxiety. Future research and development efforts must also address social cognitive functions like these to ameliorate the range of deficits that impede the social functioning of schizophrenia patients.
Acknowledgements This study was made possible in part by a grant from the Illinois Department of Mental Health and Developmental Disabilities. The authors wish to thank Drs. David Penn and Stanley McCracken for their comments about earlier versions of the manuscript.
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Some evidence from reaction time measurements. Percept. Psychophys. 2, 45-53. Stokes, T.F. and Baer, D.M. (1977) An implicit technology of generalization. J. Appl. Behav. Anal. 10, 349-369. Venables, P,H. (1964) Input dysfunction in schizophrenics. In B.A. Maher (Ed.), Progress in Experimental Personality Research, ( Vol. 1). Academic Press, New York. Wagner, B.R. (1968) The training of attending and abstracting responses in chronic schizophrenia. J. Exp. Res. Personal. 3, 77-88. Wallace, C.J. and Liberman, R.P. (1985) Social skills training for patients with schizophrenia: A controlled clinical trial. Psychiatry Res. 15, 239-247. Wolf, F.M. (1986) Meta-analysis: Quantitative Methods for Research Synthesis. Sage, Beverly Hills, CA.
ELSEVIER
Memory and vigilance training to improve social perception in schizophrenia Patrick W. Corrigan *, Joyce Nugent Hirschbeck, Michelle Wolfe Llniversity of Chicago Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tinley Park, IL 60477. USA Received 28 November 1994; revision received 23 January 1995; accepted 30 January 1995
Abstract
Previous research has suggested that social cue recognition in schizophrenia may be significantly associated with visual vigilance and verbal memory. Therefore, we predicted that subjects who participated in a cognitive rehabilitation program that incorporated vigilance and memory training strategies would show significantly better social cue recognition than subjects participating in vigilance training alone. Forty subjects with a DSM-III-R diagnosis of schizophrenia or schizoaffective disorder were randomly assigned to either a vigilance-alone or a vigilance-plusmemory training condition. Results showed that subjects in the vigilance-plus-memory condition were able to identify social cues in the videotaped training materials significantly better than subjects in the vigilance-alone condition. This difference was evident in an independent measure of social cue recognition and was present at a 48 h follow-up. Implications for future development of cognitive rehabilitation for schizophrenia were discussed. Keywords: Social cue recognition; Memory training; Vigilance training; (Schizophrenia)
1. Introduction
Clinical research has consistently shown that, in concerl with careful titration of neuroleptic medication, behavioral rehabilitation strategies, like social skills training, effectively reverse the downhill trend in the deteriorating interpersonal skills of some schizophrenia patients. Patients participating in social skills training programs have been found to increase their range of prosocial behaviors, to diminish their psychotic symptoms, and to decrease their time in the hospital (Bellack et al., 1984; Hogarty et al., 1986, 1991; Wallace * Corresponding author. 0920-9964/95/$09.50© 1995ElsevierScienceB.V. All rights reserved SSD1 0920-9964(95)00008-9
and Liberman, 1985). These effects seem to be limited, however; many patients who demonstrate significant cognitive deficits seem to be refractory to traditional skills training strategies (Liberman et al., 1985; Massel et al., 1991). Therefore, development of cognitive rehabilitation strategies may facilitate social skill learning and may improve overall interpersonal functioning. In order to meet this goal, research teams have attempted to conceptualize interpersonal functioning and social skills training in terms of information processing functions (Bellack et al., 1989; Corrigan, Schade and Liberman, 1992). Recent studies have evaluated the relationships between two information processing functions - visual
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vigilance and verbal recall 1 - and domains of social cognitive functioning including psychosocial skill learning and social cue recognition. In terms of psychosocial skill learning, studies have found significant relationships between skill acquisition and measures of visual vigilance (Bowen et al., 1994; Kern et al., 1992) and short term, verbal recall (Corrigan et al., 1994; Kern, Green and Satz, 1992; Mueser et al., 1991). A similar pattern was found with social cue recognition. Social cue recognition has been distinguished from other information processing tasks by the content of these tasks which are believed to be more ecologically valid (Ostrom, 1984; Penn et al., 1994). The foci of social cue recognition tasks are concerned with relatively molar information, focus on behavioral and individual differences, tend to be labile, act as their own causal agent, and interact with the perceiver. One study examined the relationship between social cognition and information processing measures. Results showed social cue recognition to be significantly associated with both recall memory and visual vigilance (Corrigan et al., 1994). Therefore, improving deficits in social cue recognition seemed like a logical first step in remediating cognitive dysfunctions that interfere with social skill learning and interpersonal competence, and therefore was the target of the cognitive interventions discussed in this paper. Findings from the above literature on descriptive psychopathology suggest that cognitive rehabilitation strategies which attempt to improve recognition of interpersonal cues might be more successful when incorporating interventions that address deficits in vigilance and recall memory. Reviews of the literature on cognitive rehabilitation of schizophrenia have showed, however, that most studies have used various 'vigilance' strategies alone as the basis of their rehabilitative approach (Corrigan 1 Information processing is a complex construct that has been explained by various models including serial processing (Sternberg, 1966, 1967), cognitive capacity (Kahneman, 1973), and parallel distributed processing (McLeUand et al., 1986). Description of these models exceeds the scope of this paper. The two processes targeted in this paper were selected because they have been widely studied in laboratory-based research of cognition in schizophrenia (Nuechterlein and Dawson, 1984).
and Storzbach, 1993; Green, 1993). Investigators conducting vigilance enhancement studies assumed that primary deficits in vigilance accounted for subsequent deficits in memory; therefore, remediation of vigilance deficits should clear memory dysfunctions (McGhie and Chapman, 1961; Silverman, 1964; Venables, 1964). Despite this assumption, few studies of cognitive rehabilitation have actually examined the effects of remediated vigilance on more complex memory and encoding studies. One well-controlled study failed to find an association between improvements in vigilance processes and subsequent increments in encoding and memory (Wagner, 1968). If this dissociation is supported in future studies, then significant improvement of social perception may not be addressed sufficiently by 'vigilance' interventions alone. Much of this research has been completed on laboratory-based stimuli; interventions targeting social cognitive deficits have been lacking. The purpose of this study was to compare the effects of two cognitive rehabilitation approaches on the social cue perception of patients with schizophrenia. Vigilance training alone was contrasted to a training package that combined vigilance enhancement and semantic encoding; the latter intervention had been shown to remediate recall memory deficits in schizophrenia (Koh et al., 1976). Vigilance-plus-memory training was expected to yield superior effects on social cue recognition than vigilance-alone.
2. M e ~ o ~
2.1. Subjects Forty-six individuals who were either inpatients at Tinley Park Mental Health Center (n---18) or outpatients at the University of Chicago Partial Hospitalization Program (n= 28) were asked to participate in this study. Patients who agreed to participate were initially included if they had: a DSM-III-R chart diagnosis of schizophrenia or schizoaffective disorder, were between the age of 18 and 55 years, had no chart history of substance abuse in the past six months nor any history of tolerance or withdrawal during their lifetime, had
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corrected vision of at least 20/30 as measured on the Snellen Eye Chart, exceeded a third grade reading level as measured on the Wide Range Achievement Test-Revised (Jastak and Wilkinson, 1984), and had no chart history of neurological disorder or developmental disability. DSM-III-R diagnoses were validated by completion of the Mood and Psychotic Symptoms Modules of the Structured Clinical Interview for DSM-III-R (SCID: Spitzer et al., 1990). In addition, the Psychoactive Substance Use Disorders Module from the SCID was administered to assess history of recent drug dependence or abuse. The SCID was administered by individuals trained to a kappa of at least 0.60 with consensus criteria from our lab. Fort) subjects participated in the study; six declined to participate. The sample had a mean age of 35.3 years (SD= 10.1) and had completed 12.6 (SD=2.1) years of education on average. Subjects were 55% female, 57.5% African American and 42.5% white. Seventy-five percent of the sample was single, 10% was married, and 15% was divorced or widowed. On average, the sample had spent 60.7 (SD =73.6) of the previous 180 days in the hospital; 35.0% of the sample were inpatients at the time of the study. Thirty-eight of the patients received antipsychotic medication; mean dose in chlorpromazine equivalents equaled 711 mgs (SD=522). Seventeen patients received benztropine for side effects; mean dose equaled 3.5 rags (SD=3.6). 2.2. Predictor measures
Patients selected to participate in the study completed two measures that have been shown to be significantly associated with performance on the social cue recognition tasks: verbal recall/ recognition and psychiatric symptomatology (Corrigan et al., 1994). 2.3. Rev auditory verbal learning task (RAVLT)
Ability to recognize and recall word lists was measured by administering the RAVLT (Rey, 1964). Subjects were instructed to listen to a list of 15 common words read by the examiner. When
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the examiner finished the list, subjects repeated aloud as many of the words as they could remember. The examiner then repeated the entire list two more times with subjects recalling words at the end of recitation. The recall score equaled total number of correctly identified words for the three trials. After a fifteen minute interference task, subjects were instructed to read a paragraph and circle words that were included in the stimulus list. Number of correctly circled words represented the recognition score. 2.4. Brief psychiatric rating scale (BPRS)
Subjects were administered the expanded version of the BPRS to measure psychiatric symptoms (Lukoff et al., 1986). Raters conducting BPRS interviews were previously trained to a minimum intraclass correlation coefficient (ICC( 1,1 ): Shrout and Fleiss, 1979) of 0.80 according to criterion ratings established at our lab. Two summary scores, identified in a factor analysis by Overall et al. (1967) were determined: a Thinking Disturbance Factor (conceptual disorganization + hallucinations + unusual thought content) and a Withdrawal/Retardation Factor (blunted affect + emotional withdrawal + motor retardation). 2.5. Training conditions
After completing the predictor variables, patients were randomly assigned to either vigilance-alone or vigilance-plus-memory training. To diminish variables that might confound training effects, the stimulus materials, training environment, and length of training sessions were similar across conditions. The stimulus material for both training conditions was eight videotaped vignettes from the Social Cue Recognition Test (SCRT: Corrigan and Green, 1993). SCRT vignettes are 30 to 45 s long and include two or three actors engaged in either low emotion (e.g., two friends assembling a puzzle) or high emotion (e.g., a husband and wife fighting about their children) situations. All training sessions were conducted in the cognition laboratory at the University of Chicago Center for Psychiatric Rehabilitation.
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Training in both conditions was completed in one 60-minute session. Vigilance training comprised three strategies self-instruction, salient cues, and repeated practice that had been shown to improve the vigilance of schizophrenia subjects on information processing tasks (Meichenbaum, 1969; Meiselman, 1973). During a typical training session, subjects were seated in front of the video monitor on which SCRT vignettes were presented and asked whether they were 'ready to attend to the task' prior to presenting the vignette. They were then given a card with a self-instructional message prior to each vignette which they were told to say aloud (e.g., 'The scene is going to flash on the screen soon. I should watch with my eyes and listen with my ears.'). Subjects were then shown the videotaped vignettes twice to facilitate repeated practice. Training per se requires patients to 'learn something' as a result of the intervention. In vigilance training, patients learned to self-instruct a message about attending to the stimulus array. Vigilance-plus-memory training combined the three strategies discussed above with semantic elaboration, a neuropsychological training strategy that has been shown to remediate memory deficits (Gouvier et al., 1986; Koh et al., 1981; Koh et al., 1976). When participating in semantic elaboration, subjects were instructed, prior to viewing the vignette, to put the gist of the story in their own words. The self-instructional message was, 'I should try to put the story into my own words'. After viewing the vignette, subjects in the vigilance-plus-memory condition were asked to say aloud what happened in the story. Subjects who were not able to report key aspects of the situation, as outlined in the training manual, were asked questions by the examiner that facilitated encoding of the situation: 'What did the actors say in this situation? What did they do in this situation? Why did they say (or do) that? How do you think they felt in this situation? What do you think may happen next?'. Subjects were urged to put responses in their own words rather than repeat the actors' lines. Subjects were also provided a list of 'feeling words', divided into 'good' and 'bad' feelings, to help them choose responses to the question about how actors felt in the situation. -
2.6. Training fidelity Trainers conducting the sessions (JNH and MW) had met competency criteria on each condition during two pilot sessions prior to working with patients. Actual training sessions were also videotaped and subsequently rated by two independent raters on a measure of fidelity that summarized the competency criteria. The fidelity instrument contained 137 training behaviors which trainers were supposed to demonstrate during the sixty minute session; trainers were expected to show 63 behaviors when engaged in vigilance training and 74 behaviors for vigilance-plusmemory. Sixteen of the forty training sessions were randomly selected and rated by two independent raters on the fidelity checklist; raters were blind to hypotheses of the study and patient's training condition. The occurrence agreement (Hartmann, 1982) representing their interrater reliability was 0.92. The mean percent of training behaviors observed for each of the training strategies was 95.1% for vigilance alone and 94.2% (SD = 5.1 and 6.8) vigilance-plus-memory. 2. 7. Dependent measures Immediately after completing training exercises on each of the SCRT vignettes, subjects answered 36 true-false questions about that vignette. Hence, the sixty minute training session included the time necessary to conduct the vigilance-plus-memory or vigilance-alone training and the time to answer the 36 true-false questions for each of the vignettes. A sample question was 'True or false. At the end of the scene, Carl sat down at the table'. Previous research on the SCRT showed these questions to be reliable and valid measures of the social cue recognition of severely mentally ill adults (Corrigan et al., 1990; Corrigan and Green, 1993). Social cue recognition was also assessed on an independent measure of cue recognition - the Cue Recognition Test (CRT: Corrigan et al., 1992) after the sixty minute training session was completed. The CRT consists of eight videotaped vignettes depicting persons involved in interpersonal problems. Subjects answer eighteen true-
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false questions after each vignette; e.g., 'True or false. Barbara is standing at the front of the line'. The CRT has been shown to be reliable and correlates highly with SCRT performance (Corrigan et al., 1992). The tests of social cue recognition (the SCRT and the CRT) each yielded two outcome measures: correct identification rate (percent of true items reported as true) and false alarm rate (percent of false items reported as true). These indices may be biased, however, by the perceived payoffs for correct identifications and perceived penalties for incorrect attributions (Davies and Parasuraman, 1982). For example, subjects participating in a study where they are reimbursed $5.00 for correct identifications are more likely to say false items are true than subjects who are fined $5.00 for false alarms. Therefore, a nonbiased measure of cue sensitivity (A') was determined from correct identification and false alarm rates for the SCRT and CRTZ; this has been shown to be a valid index of memory in general (Snodgrass and Corwin, 1988), and of social cue recognition in particular (Corrigan and Green, 1993). To assess maintenance of training effects, the SCRT and CRT were re-administered at a 48 hour follow-up.
3. Results
The mean and standard deviations of demographic and predictor variables for the vigilanceplus-memory and vigilance-alone training conditions were summarized in Table 1. The two groups participating in each condition were not found to differ significantly on gender, marital status, age, education, or days hospitalized during the previous six months (p > 0.20). The two groups were shown to differ in terms of ethnicity, with more African Americans being randomly assigned to the vigilance-alone training condition (Xz = 5.01, p < 0.05 ). None of the demographic variables in Table 1 were
1 (CI-FA)(I+CI-FA) 2A' = 9 q4CI(1 - F A ) where CI=correct identification and FA=false alarm rate.
Table 1 Means and standard deviations of demographic and predictor variables for the vigilance-plus-memory and vigilance-alone training conditions Vigilance-plus-memory Vigilance-alone training training (n=20) (n=20) Gender Ethnicity Marital status
Age Education Antipsychotic dose Benztropine dose Days hospitalized BPRS Think Disturb BPRS With/Retard Rey Recall Rey Recognition
55.0% female 60.0% white 40.0% afr amer 75.0% single 5.0% married 20.0% wid/div 35.9 _+10.9 12.6 +_2.2 705 + 513 3.8 +_3.7 59.9 +_74.1 7.8_+3.2 4.5_+2.2 19.7 + 6.2 9.9 +4.0
55.0% female 25.0% white 75.0% afr amer 75.0% single 15.0% married 10.0% wid/div 34.7 _+9,5 12.6 +_2.0 717 + 531 3.3 _+3.6 61.6 +__75.1 7.4+3.4 5.2_+2.5 17.8 _+4.4 10.3 _+3.9
BPRS: Brief Psychiatric Rating Scale
found to covary significantly with A' on the SCRT or CRT (p>0.15). No significant differences were found in predictor variables (i.e., RAVLT and BPRS) across groups (p >0.20). The correlations between these variables and the social cue recognition outcome measures are summarized in Table 2. Results seem to support earlier research which showed a significant association between verbal memory and social cue recognition (Corrigan et al., 1994). In particuTable 2 Pearson product moment correlations between predictor measures and measures of cue sensitivity (SCRT A' and CRT A'I at post-test and follow-up SCRT A'
CRT A'
Post-test Follow-up Post-test Follow-up BPRS Think Disturb - 0 . 2 2 -0.15 -0.11 -0.12 BPRS With/Retard -0.27 -0.37 -0.19 -0.20 Rey Recall 0.43** 0.41"* 0.36* 0.26 Rey Recognition 0.42** 0.50*** 0.48** 0.37* * p<0.05. ** p<0.01. *** p<0.001 Correlation coefficients in italics met the Bonferroni Criterion for significance.
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lar, seven of the eight correlation coefficients representing associations between social cue recognition and verbal memory were significant; two of these associations met the Bonferroni criterion for significance. Contrast this pattern to the associations between psychiatric symptoms and social cue recognition. Only one correlation coefficient was significant, the association between Withdrawal/ Retardation on the BPRS and the SCRT sensitivity score at follow-up. No significant associations were found between Thinking Disturbance and any of the measures of social cue recognition. Despite this pattern, results of a statistical test for differences between correlations showed only one pair of correlation coefficients - the coefficient representing the association of Thinking Disturbance and post-test CRT A' versus the coefficient representing the association of Rey Recognition with follow-up SCRT A' - to be significantly different
(p<0.05). 3.1. Differences in vigilance-plus-memory versus vigilance-alone training conditions Means and standard deviations for the sensitivity (A') of SCRT and CRT scores at post-test and follow-up are summarized in Table 3. Results of a 2 x 2 MANOVA (condition by trial) with SCRT and CRT A's as the dependent measure showed a significant main effect for condition (F(1,38)= 5.65, p < 0 . 0 5 ) but not for trial (F(1,38)=0.02, n.s.) or the interaction (F(1,38) = 0.02, n.s.). Table 3 Scores on the Social Cue Recognition Test (SCRT) and the Cue Recognition Test (CRT) for subjects in the vigilance-plusmemory and vigilance-alone conditions after training and at 48 h follow-up
SCRT A r CRT A'
Vigilance-plusmemory training (n=20)
Vigilance-alone training (n=20)
Post-test
Follow-up
Post-test
Follow-up
0.89 (0.04) 0.93 (0.05)
0.89 (0.05) 0.93 (0.04)
0.83 (0.09) 0.88 (0.07)
0.84 (0.10) 0.88 (0.11)
Standard deviations included parenthetically.
A subsequent 2 x 2 ANOVA with SCRT A' as the dependent variable showed a significant effect for condition (F(1,38) = 5.53, p < 0.05). The trial effect and interaction were non-significant (F(1,38)=0.04 and F(1,38)=0.29 respectively). Post hoc oneway ANOVAs showed that SCRT A' was significantly higher for subjects in the vigilance-plus-memory training condition, compared to individuals in the vigilance-alone condition, at post-test (F(1,38)=6.43, p<0.05) and at followup (F(1,38) =4.30, p<0.05). A 2 x 2 ANOVA was also conducted with CRT A' as the dependent variable; it showed a significant effect for condition (F(1,38)=4.68, p <0.05) but not trial (F(1,38)=0.00) or the interaction (F(1,38)= 0.23). Post hoc oneway ANOVAs also showed that CRT A' was significantly higher for subjects in the vigilance-plus-memory training condition, compared to vigilance-alone at post-test (F(1,38) = 5.43, p < 0.05). Nonsignificant trends suggested a between group CRT A' difference at follow-up (F(1,38) = 3.63, p = 0.06).
4. Discussion Subjects in a vigilance-plus-memory enhancement condition were better able to recognize social cues presented in videotaped vignettes than subjects participating in a vigilance-alone, control condition. This effect was shown on both the stimulus materials on which training was conducted, as well as on an independent measure of social cue recognition. Therefore, the combination of semantic elaboration and self-instruction seems to yield greater cue recognition scores than vigilance strategies alone. The post hoc analysis illustrates one of the short falls in this study; namely, the size of the vigilanceplus-memory effect was not determined directly by collecting SCRT scores prior to conducting the rehabilitation intervention. A repeated measures design would allow the reader to determine the extent of change from baseline. The SCRT could not be administered at pretest in this study, however, because vignettes from the measure were used as training materials in the study. This problem
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could be obviated in future research by using training materials from other videotaped vignettes. Findings from this study showed that significant differences in the effects of vigilance-plus-memory versus vigilance-alone were present 48 hours later. Maintenance of therapeutic effects is an important finding, especially if it is replicated in subsequent research in which longer follow-ups are used. It is unclear from this study, however, whether maintenance of treatment effects is due to change in the theoretical mechanism that accounts for social cue recognition (e.g., improved social recall memory per se) or to learning a cognitive prosthetic (i.e., the self-instructional message) that, when used in the future, will help subjects perceive social situations better. Future research can resolve this question by randomly assigning subjects to semantic elaboration plus self-instruction versus semantic elaboration alone. Some researchers argue that clinicians need to strategically incorporate interventions into a treatment protocol which will maintain a treatment effect over time rather than assume that improvement will naturally endure (Stokes and Baer, 1977). Therefore, we expect that self-instruction will be the essential component for maintaining the treatment effect in this study. We attributed the significant vigilance-plusmemory effect to improvement of the recognition and recall memory of participating subjects. This finding is consistent with earlier research which showed that word and facial recognition improved significantly in patients who participated in semantic elaboration (Koh et al., 1981; Koh et al., 1976). However, neither the studies conducted by Koh and his colleagues nor the research described in this paper has shown that this effect is specifically due to improved recall or recognition. Future research would need to include independent evidence of improvement in recall or recognition after training to assert the specificity of our finding. Alternatively, perhaps the combination of selfinstruction and semantic elaboration therapeutically improves an earlier stage in the information processing series (e.g., vigilance) which subsequently enhances memory. Attempts to isolate the effects of cognitive interventions vis-a-vis specific information processes are difficult because of the serial nature of cognition. Nevertheless, the effort
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is important for practical reasons. Demonstrating that the vigilance-plus-memory procedure used to improve social cue recognition in fact enhanced recall memory suggests that other memory enhancement procedures (e.g., guided imagery, use of mnemonics) may also be helpful for schizophrenia patients (Corrigan and Yudofsky, in press). Morrison and Bellack (1981) have argued that patients who perceive and understand social cues may demonstrate relatively better social functioning. Therefore, improvement of interpersonal cue recognition is likely to correspond with a concomitant gain in social learning and social skill. However, increments in social cue recognition alone are probably not sufficient to improve social functioning. The macro construct of social functioning comprises several other social cognitive components - comprehension of the rules that define a social situation, development of a response to the demands of a situation given these rules, retrieval of various actions that may be appropriate to the response - which may be deficient in schizophrenia subjects. Change in these functions may yield clinically meaningful changes in prominent symptoms like paranoia and social anxiety. Future research and development efforts must also address social cognitive functions like these to ameliorate the range of deficits that impede the social functioning of schizophrenia patients.
Acknowledgements This study was made possible in part by a grant from the Illinois Department of Mental Health and Developmental Disabilities. The authors wish to thank Drs. David Penn and Stanley McCracken for their comments about earlier versions of the manuscript.
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